INTRODUCTION — Local treatment of burn wounds includes cleansing and debridement and routine burn wound dressing changes, typically incorporating topical antimicrobial agents; however, there is no consensus on which agent or dressing is optimal for burn wound coverage to prevent or control infection or to enhance wound healing [1,2].
The selection and application of burn wound dressings and topical agents depends on the nature and extent of the burn wound, a particular wound quality or state (eg, contamination, infection), and the patient's allergy history. The dressings and topical therapies that are used at a given facility depend upon regional and individual preference and experience, availability, and costs.
The most frequently used burn wound dressings and topical agents in adults and children will be reviewed here. The classification and management of burns by depth of burn and the specialized management of burns at specific anatomic sites are reviewed separately. (See "Assessment and classification of burn injury" and "Treatment of minor thermal burns" and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burn injury".)
LOCAL BURN WOUND CARE
Goals — Local burn wound care (table 1 and table 2) aims to protect the wound surface, maintain a moist environment, promote burn wound healing, and limit burn wound progression while minimizing discomfort for the patient [3]. It is important to note that topical antimicrobials are used in conjunction with appropriate basic wound care. (See "Basic principles of wound management".)
Burn wound surfaces are prone to rapid bacterial colonization with the potential for invasive infection. Measures to reduce the likelihood of infection include good infection control practices, topical antimicrobial therapy, and burn wound debridement/excision, when needed [4]. Closed dressing management is often advocated to minimize cross-contamination by pathogens (eg, methicillin-resistant Staphylococcus aureus) that can cause burn wound infection, delayed wound healing, and loss of skin grafts [5]. Wounds that become infected require systemic antimicrobial therapy, in addition to the chosen regimen for local wound care. (See "Burn wound infection and sepsis".)
Dressings — A variety of antimicrobial agents (see 'Antimicrobial agents' below) can be applied to the burn wound surface, which is then covered with one of several dressing materials (eg, gauze, nonadherent films) (table 1 and table 2).
Early after injury, it may be difficult to accurately determine the depth of burn wounds, and, since burn wounds are often of mixed depths, more than one local wound care regimen may be necessary. Our approach to local burn wound care based on burn wound depth (table 3) is summarized briefly below and discussed in more depth elsewhere. (See 'Efficacy and use of topical therapy' below and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burn injury".)
Gauze alone should be avoided unless there are no other options (ie, topical antimicrobials are not available). Dry gauze promotes scab formation, which will generally separate spontaneously as reepithelialization occurs. However, pain can be significant when the gauze is removed.
Nonadherent films or fine mesh gauze (in combination with topical antimicrobials) are common dressings used to cover the burn wound, but films, foams, alginates, hydrocolloids, and hydrogels can also be used depending on the specific qualities of the dressing (eg, silver containing) and the specific needs of the burn wound. These can either cover a burn wound treated with a topical agent or be applied directly to the wound. As examples, partial-thickness burns have moderate-to-high amounts of exudate, which are appropriately managed with foams and alginates. By comparison, for a graft donor site that has minimal-to-moderate exudate, the use of polyurethane, hydrocolloids, or hydrogels may be adequate.
Coverage of clean, uninfected burn wounds can also be accomplished using biologic dressings or skin substitutes. These are applied once and adhere to the wound, separating spontaneously as healing progresses [6]. (See 'Temporary burn wound coverage' below.)
Dressing changes should be frequent enough to control exudate but not so frequent that they interfere with wound reepithelialization. The frequency ranges from twice daily to weekly depending upon the amount of exudate and choice of dressing material. More frequent dressing changes are performed if there is a large amount of exudate, weeping, or infection [7].
Topical antimicrobials should be gently removed with dressing changes. Excessive scrubbing and sharp debridement is not necessary and may hinder healing. Management of pain in association with burn wound care is discussed separately. (See "Treatment of superficial burns requiring hospital admission", section on 'Pain management' and "Paradigm-based treatment approaches for management of burn pain", section on 'Procedural pain' and "Management of burn wound pain and itching".)
ANTIMICROBIAL AGENTS — Commonly used topical agents include combination antimicrobial ointments, silver sulfadiazine, bismuth-impregnated petroleum gauze, mafenide, and chlorhexidine [1,2,8,9]. Other agents such as honey, povidone-iodine, and Dakin's solution are less commonly used. Combinations of antimicrobials with topical antifungal agents have also demonstrated some efficacy for the local treatment of burns [10].
Some of the agents have variable degrees of local or systemic adverse effects and may impede wound healing (table 1) [1,4,11]. However, there is no official standard for testing the efficacy and cytotoxicity of topical antimicrobial agents [12].
Commonly used agents — Commonly used topical agents for partial-thickness burns include antimicrobial ointments, silver-containing agents, bismuth-impregnated petroleum gauze, chlorhexidine, and mafenide [8,9].
Antimicrobial ointments — Topical antimicrobial ointments (as single agents or combination agents) are commonly used for superficial burn wounds. Compared with silver sulfadiazine, the advantages of these are ease of application and of removal for wound cleansing. In addition, these can be used in areas of sensitivity, such as on the face, ears, and perineum (table 1).
Polysporin is a combination of bacitracin zinc and polymyxin B sulfate. It can be used to treat partial-thickness burns, particularly those that involve the face and perineum [9]. For uncomplicated wounds, many clinicians apply Polysporin ointment covered by a nonadherent dressing. However, its efficacy in the treatment of infected wounds has not been clearly established. In the setting of methicillin-resistant Staphylococcus aureus (MRSA), mupirocin ointment/cream is effective [13]. Areas near the eyes are generally managed with ophthalmic derivatives, such as neomycin or erythromycin ophthalmic ointment. Otherwise, the use of neomycin is generally limited to smaller burn areas. It is frequently mixed (diluted) with bacitracin and polymyxin to reduce absorption [9].
Bacitracin, neomycin, and polymyxin B have negligible systemic absorption after topical administration except when applied to large areas or for long periods of time. Polymyxin B has little absorption even when applied to open wounds. However, systemic absorption has been reported when bacitracin, neomycin, or gentamicin has been applied to damaged epithelium [14]. If absorbed systemically, bacitracin, neomycin, or polymyxin B can cause nephrotoxicity and neurotoxicity. Caution should be used in patients with impaired renal function and in those taking additional medications with nephrotoxic or neurotoxic adverse effects. An alternative is to limit the duration of use and/or to alternate with topical agents that are not absorbed.
Silver-containing agents — Silver-containing agents slowly release ionic silver into the wound (table 1). Activated silver has broad-spectrum antimicrobial activity and may also have an anti-inflammatory benefit [15]. There are several silver-containing preparations and dressings, including silver sulfadiazine, nanocrystalline silver (eg, Acticoat, Aquacel Ag), and silver nitrate, each of which has its own management requirements. Silver formulations that contain silver nitrate and silver sulfadiazine require more frequent dressing changes.
Silver sulfadiazine — Silver sulfadiazine cream (SSD 1%) applied and covered with fine mesh gauze is the most commonly used burn wound dressing [1]. SSD is widely available and relatively inexpensive and continues to be used in many burn centers as the standard of care for the treatment of burn wounds, with a long history and experience with its use.
SSD has antimicrobial activity as demonstrated by decreased colonization of burn wounds. However, there are no well-designed trials to confirm improved wound healing or a reduced rate of bacterial wound infection [1,16]. For wounds covering more than 50 to 60 percent of the total body surface area, SSD does not consistently prevent or suppress bacterial growth, particularly of gram-negative bacteria [17]. In addition, there are potential adverse effects. As an example, SSD will form a pseudoeschar that is loose at the edges, which can promote bacterial proliferation. The pseudoeschar requires removal or debridement to improve the ability to monitor the wound state and facilitate reepithelialization. SSD also impedes reepithelialization; as a result, SSD should be stopped when there is evidence of reepithelialization [1].
SSD is a thick white cream that is applied once or twice daily and can be soothing. SSD and related agents should not be used in women who are pregnant or breastfeeding or in infants younger than two months old [18]. SSD is also oculotoxic and should not be used near the eyes [19].
Cerium nitrate, one of the lanthanide rare earth elements, can be added to SSD for burns not undergoing immediate excision and closure [17,20-22]. Reports in adult and pediatric burn populations have been conflicting regarding the clinical value of cerium as measured by mortality, length of hospital stay, and bacterial colonization of the wounds. In two trials in the Cochrane review, there were fewer deaths in groups treated with cerium nitrate plus SSD compared with SSD alone (relative risk [RR] 0.22, 95% CI 0.05-0.99 [20,23]). Other studies that did not address these clinical outcomes have found that SSD-cerium was not more effective than SSD alone in reducing burn wound colonization [24,25].
Nanocrystalline silver — Nanocrystalline silver dressings are composed of a urethane film embedded with elemental silver that provides sustained release of silver into the wound. Compared with older silver formulations, it has stronger antimicrobial activity and longer-lasting properties that reduce dressing change frequency to weekly, depending upon the amount of exudate [26]. Some nanocrystalline silver dressings (eg, Acticoat) require frequent moistening with water to maintain activation.
In a systematic review, compared with SSD, nanocrystalline silver had a lower incidence of infection (9.5 versus 27.8 percent, odds ratio 0.14, 95% CI 0.06-0.35) [27]. Nanocrystalline silver was also associated with less pain during change of dressings and lower cost.
In a trial comparing Acticoat with Allevyn (an occlusive moist-healing environment material), skin graft donor sites dressed with Allevyn reepithelialized at a faster rate [28]. The opposite effect was found in another trial in which wounds treated with Acticoat reepithelialized faster with better comfort compared with Allevyn [29]. Both studies agreed that there was no difference in bacterial colonization of the donor site.
Bismuth-impregnated petroleum gauze — Bismuth-impregnated petroleum-based gauze is comparable to other topical antimicrobial agents [30,31]. Bismuth-impregnated gauze is an often preferred dressing for skin graft donor sites and for covering fresh skin grafts, and it is also an excellent option for very small superficial partial-thickness burns where clinical judgment indicates antimicrobial activity is necessary.
Bismuth-impregnated gauze is applied as a single layer over the burn and then covered with a bulky dressing [18]. The dressing will separate from the wound when it has reepithelialized. Bismuth-impregnated petroleum gauze is particularly useful in children as it is applied only once, decreasing the pain that typically accompanies wound dressing changes.
Mafenide acetate — Mafenide acetate (table 1), a potent carbonic anhydrase inhibitor, is an alternative to SSD and may be useful for treating patients with dense bacterial proliferation of the burn wound [32-36]. In a study of 669 burn patients treated with 5% mafenide solution as either the initial topical antimicrobial agent (276 patients) or for chronic treatment, effective activity was achieved, and only 1 percent experienced pain severe enough to discontinue therapy [36]. There was a very low incidence of rash and pruritus and no cases of metabolic acidosis.
Mafenide acetate can also be applied as a cream applied once or twice daily at a thickness of approximately 1/16 of an inch [37]. Treatment is typically continued until the burn site is healed or ready for skin grafting.
Adverse reactions associated with use of mafenide include metabolic acidosis, allergic reactions (eg, rash, pruritus, hives, erythema, eosinophilia), and respiratory complications (eg, tachypnea, decrease in arterial pCO2) [38,39].
Chlorhexidine — Chlorhexidine gluconate (table 1), a long-lasting antimicrobial skin cleanser, is often used with a gauze dressing for burn wound coverage in superficial partial-thickness burns. Chlorhexidine dressings do not interfere with wound reepithelialization, in contrast to silver sulfadiazine [1]. A combination preparation of silver sulfadiazine and chlorhexidine gluconate has also been used [40,41].
Others
Honey — Honey-derived wound care dressings heal limited superficial partial-thickness wounds as well as, or better than, several other conventional treatment options such as polyurethane film, paraffin gauze, Soframycin-impregnated gauze, sterile linen, or leaving the burns exposed [42,43]. However, the safety, efficacy, and use of honey-based dressings for the treatment for more severe, extensive, or complex thermal injury has not been established.
There are few high-quality studies, but evidence from low-quality studies and anecdotal reports in burn patients suggest that honey-derived wound care dressings are generally well tolerated and may show adjunctive efficacy in the treatment of a variety of wound types [1]. In a systematic review comparing honey dressings with silver sulfadiazine, honey improved healing time (mean difference [MD] -5.76 days, 95% CI -8.14 to -3.39) and the proportion of infected wounds rendered sterile (RR 2.59, 95% CI 1.58-2.88) [43]. An earlier systematic review similarly supported the use of honey in burn wound care while noting the generally low methodologic quality of the available randomized trials [44].
Povidone-iodine — Povidone-iodine ointment, including a liposomal preparation, effectively combines antimicrobial therapy with a desired moist wound environment. Despite a broad spectrum of antimicrobial activity [45,46], use of povidone-iodine-containing products in burn care is controversial because of cytotoxicity and delay in wound reepithelialization [11,45,47]. Another drawback to povidone-iodine ointment compared with other topical agents is that it must be applied four times a day for maximal antimicrobial effect.
Dakin's solution — Dakin's solution (0.025% sodium hypochlorite) is widely used in a variety of difficult wound types and has been advocated by some for the management of burn wounds. It has broad-spectrum antimicrobial activity with efficacy in the clinical setting of MRSA, Vancomycin-resistant Enterococcus (VRE), and other antibiotic-resistant bacteria [48].
Proponents of Dakin's solution note its broad spectrum of action, minimal cost, and cytoprotective benefits (little impact on fibroblast function). While there are few well-defined papers to strongly advocate its use in burns, it may hold promise, particularly in settings where funding and availability of other standard dressing regimens are lacking. Pain control issues have been noted [48].
DEBRIDING AGENTS — Enzymatic debriding agents and proteolytics have been successfully used for the early management of deeper and indeterminate depth surgical burn wounds and eschar for many years [49-55]. The aim of using these agents is expedited debridement while affording a measure of specificity and dermal preservation. Products have included collagenase derivatives, a variety of fruit enzyme derivatives such as the papain/urea derivatives, as well as bromelain derivatives. The later generation of products have demonstrated greater specificity to eschar. One bromelain derivative, anacaulase (NexoBrid), has been granted approval for use in the United States [49], European Union [56], other international markets for the treatment of small- to moderate-sized intermediate and deep dermal thickness burn wounds. Cautions include attention to potential bleeding risk, allergies, as well as adequate analgesia.
TEMPORARY BURN WOUND COVERAGE
Biologic grafts — Biologic graft materials that can be used for temporary coverage of burn wounds include allografts, xenografts, and others (eg, human amnion). These help promote healing or can serve as a bridge to definitive burn wound coverage. Skin autografts and the use of dermal generation templates for permanent coverage for burn wounds are discussed separately. (See "Overview of surgical procedures used in the management of burn injuries" and "Skin autografting".)
Biologic grafts can be used on clean burn wounds, and they protect the wound from desiccation while promoting reepithelialization. The graft separates from the wound once it has reepithelialized. Biologic grafts are especially useful in children as they are applied only once, decreasing the pain that typically accompanies wound dressing changes.
●Allografts – Transient physiologic coverage can be achieved by allogeneic skin grafts (eg, from a nongenetically identical donor from the same species, also called homograft). Allografts are distributed as either fresh or cryopreserved after glycerol preservation from cadavers. The application of an allograft over superficial partial-thickness wounds can minimize pain and facilitate reepithelialization. Allogeneic skin is generally used only in burn centers.
●Xenografts – Xenografts are generally readily available but may not be as effective as allografts. Skin xenografts, obtained from an unrelated species (heterografts), are used as temporary skin coverage, especially for large burn wounds. Various animal skins have been used in the past, but only porcine grafts are currently used [57,58]. Porcine-derived xenografts do not vascularize but will adhere to a clean superficial wound, accelerate reepithelialization, and reduce pain. Xenografts are easier and cheaper to produce, and more readily available, but are not as effective as allografts. Large-dimensional sheets can be processed, facilitating coverage.
●Human amnion – Human amniotic membrane has been successfully used as a biologic dressing for partial-thickness wounds [59,60]. However, concerns regarding pathogenic transmission have limited its use. In a retrospective review of 31 studies, amniotic membrane promoted reepithelialization of the burn wound; had antimicrobial properties; and reduced pain, fluid loss, and scar formation. An allograft consisting of sterilized, dehydrated human amnion/chorion membrane (dHACM) has also been used for burn patients [61]. dHACM contains growth factors that promote wound healing, including platelet-derived growth factor A and B, basic fibroblastic growth factor, and transforming growth factor beta 1, and it is stable at ambient temperatures for five years [62,63].
Semibiologic skin substitutes — Semibiologic skin substitutes are temporary biosynthetic dressings that are meant to reduce the number of dressing changes and facilitate healing [60]. The semipermeable nature of these dressings allows wound exudate to be absorbed by the external bulky dressing. The type of skin substitute chosen depends upon the appearance of the wound, desired outcome, clinician experience, availability, cost, and cultural preferences, as some are porcine derived. (See "Skin substitutes".)
Biobrane and Biobrane-like — Biobrane is used to cover donor sites and aid in coverage of large surface area burns, including hands, feet, and joints [64-74]. Biobrane is sometimes used on full-thickness excisions as a temporary covering to protect the excised wound site in a staged fashion prior to subsequent stage skin grafting. (See "Treatment of deep burn injury" and "Overview of the management of the severely burned patient".)
Biobrane is a bilaminate membrane that contains a thin semipermeable silicone membrane bonded to a layer of nylon fabric mesh and coated with a monomolecular layer of type 1 porcine collagen [64]. The porcine collagen provides a hydrophilic coating for fibrin growth that promotes wound adherence. Biobrane has no inherent antimicrobial activity, but the membrane is porous, allowing absorption of topical antimicrobial agents and drainage of exudate. Biobrane is versatile and has additional properties of flexibility, elasticity, and transparency for wound observation.
Some biosynthetic dressings incorporate Biobrane or are of a similar nature, including Transcyte (neonatal fibroblast incorporated into Biobrane), Suprathel (resorbable caprolactone-based materials), and Omiderm (hydrophilized polyurethane membrane). AWBAT, a derivative of Biobrane, is a porous silicone-nylon membrane coated with porcine type 1 collagen [68]. The collagen is not cross-linked to the silicone membrane, which should allow for fibrin in the wound to achieve clotting and improve acute adherence, and the porosity is increased, which should reduce the fluid accumulation and the fluid pressure on the wound. Small trials have confirmed good usability, but whether its anticipated benefits relative to Biobrane will be realized is uncertain [69,75,76]. In a Cochrane review (see 'Efficacy and use of topical therapy' below), 10 trials compared the effectiveness of Biobrane or Transcyte to silver sulfadiazine or other dressings [1]. Overall, biosynthetic dressings resulted in a shorter time to healing, improved pain relief during dressing changes, had lower pain medication requirements, and resulted in a shorter length of hospital stay.
Biobrane is applied by gently stretching the fabric over the burn surface to avoid wrinkles and is secured to nonburned skin with paper strips [65]. Dry gauze is used to cover the Biobrane, and the dressings are secured with an elastic bandage. The external dressings are changed every 24 hours, and any fluid accumulating under the Biobrane is aspirated. Biobrane can be left in place for up to 14 days, then removed in a warm bath or trimmed. Healed wounds are treated with topical agents or creams. If there is evidence of a wound infection, the Biobrane is removed and the burn treated with topical antimicrobials. (See 'Antimicrobial agents' above.)
Suprathel is applied to the wound after debridement and covered with a layer of fatty gauze. A secondary dressing with cotton gauze is applied. Suprathel and the fatty gauze remain on the wound surface until healing is complete and will separate from the re-epithelialized surface [66,67]. A systematic review of 14 publications related to the use of the Suprathel for donor sites and the treatment of partial thickness burns concluded that while results regarding safety, efficacy, and ease of use are desirable, the cost and a lack of economic assessment is a major limitation for establishing recommendations for use [77].
EFFICACY AND USE OF TOPICAL THERAPY — Aggressive wound care that includes topical agents with antimicrobial activity has been associated with a reduced incidence of invasive wound infections [78,79], but the efficacy of topical therapy has not been definitively proven [1,7]. In addition, there is no consensus on which agent or dressing is optimal for managing burn wounds to prevent or control infection or enhance wound healing. The various agents are described above. (See 'Antimicrobial agents' above.)
Many randomized trials have compared the various topical agents for the treatment of burn wounds, but most are methodologically poor [1,2,9]. A meta-analysis of randomized trials concerning the topical treatment of facial burns failed to identify any specific treatment that significantly made a difference with respect to outcomes that included wound infection, scar quality, pain, and patient satisfaction [80]. A large systematic review included 56 trials with over 5800 mostly adult patients with partial-thickness burns involving less than 40 percent total body surface area (TBSA) [1]. Most studies compared a given topical agent or dressing with silver sulfadiazine (SSD). Other comparisons included alternative silver-based agents or dressings, iodine-based agents, chlorhexidine, polyhexanide, sodium hypochlorite, merbromin, ethacridine lactate, cerium nitrate, honey, aloe vera, and Arnebia euchroma. It is important to note that most comparisons did not report data on infection, which is an important clinical outcome.
The main results of this review for the treatment of superficial burns, and those of other reviews, are summarized:
●Silver versus non-silver agents – Several systematic reviews have compared various silver preparations with non-silver-containing dressings [1,16,28,81,82]. These have largely concluded that the evidence is not sufficient to establish whether silver-containing agents or dressings promote wound healing or prevent wound infection. One of these reviews suggested that there may be a detrimental effect from some silver-containing dressings [82].
In the Cochrane review, burns treated with nanocrystalline silver dressings had a shorter mean time to healing compared with Vaseline gauze (mean difference [MD] -3.49 days, 95% CI -4.46 to -2.52). There was some evidence that burns treated with honey were more likely to heal over time compared with topical antimicrobials. (See 'Honey' above.)
●Silver formulation comparison – There was no difference in the chance of healing over time comparing SSD with other silver-based agents, although other silver-based agents may have increased the number of healing events over 21- or 28-day follow-up and may slightly reduce mean time to healing [1].
In a meta-analysis of five clinical trials comparing nanocrystalline silver dressings with older silver formulation dressings (silver sulfadiazine and silver nitrate), the nanocrystalline silver group had a significantly lower rate of infections (9.5 versus 27.8 percent), decreased pain, no clear effect on hospital length of stay, and a higher cost per patient [27]. Other silver formulations (eg, Mepilex Ag) have not demonstrated differences in wound healing but have reduced numbers of dressings and lower cost compared with SSD [83].
●Non-silver agent comparisons – In the Cochrane review, there were no clear differences for comparisons between most of the agents [1]. Compared with chlorhexidine, wounds treated with povidone-iodine had a reduced mean time to healing (MD -2.21 days, 95% CI 0.34-4.08).
Whether the use of specialized dressings (eg, biologic dressings/skin substitutes) improves superficial burn wound outcomes is also uncertain. A systematic review that included 30 randomized trials (most with methodologic shortcomings) did not identify an optimal dressing type [2]. A separate review of 20 trials noted that skin substitutes were at least as effective as topical agents and wound dressings or allografts for the management of partial-thickness burns [84]. For younger patients, biologic substitutes may provide optimal coverage for superficial burns. In a review of 51 observational studies and randomized trials performed in children, biologic dressings (eg, Biobrane, DuoDerm, amnion membrane) showed better results for eschar formation, length of hospital stay, healing time, and pain scores when compared with SSD [40]. (See 'Temporary burn wound coverage' above.)
Our approach — Our approach to local burn wound is summarized and discussed in more depth in the linked topics.
Superficial burn wounds — Superficial burn wounds (superficial [epidermal], superficial partial thickness) are covered with dressing materials that aid with skin healing and reepithelialization. In general, superficial burns do not require antimicrobial therapy, but for extensive superficial burns, topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing environment. Furthermore, because superficial partial-thickness burns may not always be easily distinguished from deeper injuries, topical antimicrobial agents are often used. We generally start with a combination antimicrobial ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform, Adaptic, Mepitel). When in close proximity to the eyes, we use an ophthalmic ointment without steroids. (See "Treatment of superficial burns requiring hospital admission", section on 'Our approach'.)
Deep burn wounds — Deep burn wounds (deep partial thickness, full thickness, and deeper) require burn wound excision and graft/flap coverage. The deep burn wound site may often constitute a mixed pattern of injury with differing permeability and compromised barrier function. The role of topical agents at these wound sites is to delay the onset of an invasive infection prior to early surgical excision of nonvital tissue. The challenge is that many of these products hamper the ability of the burn team to evaluate the quality, extent, and depth of injury. As such, prior to definitive care and burn wound excision, a preliminary gauze dressing is often first applied. Excising full-thickness eschar removes the biologic and bacterial burden, decreasing morbidity and mortality while facilitating the efficacy of wound dressings, biologics, biosynthetics, and definitive coverage. Following eschar debridement and/or excision, if grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobials, typically silver-containing agents or dressings (eg, Silvadene, Sulfamylon, Acticoat), is used to provide a moist and minimally adherent provisional dressing until definitive debridement or surgical excision can be performed. Provisional coverage with allograft, biologics, and biosynthetic is applicable when the wound bed is optimized. Dressings are also used after surgery to cover and protect skin grafts and skin graft donor sites. (See "Treatment of deep burn injury" and "Overview of surgical procedures used in the management of burn injuries".)
Colonized/contaminated/infected burn wounds — When contamination with methicillin-resistant Staphylococcus aureus (MRSA) is suspected/confirmed, directed topical antimicrobial treatment (eg, mupirocin ointment/cream) should be added as a treatment [85]. Other treatments (eg, mafenide) may be more appropriate for heavily colonized or infected burn wounds (in addition to systemic antimicrobial therapy, as indicated). (See 'Antimicrobial ointments' above and "Burn wound infection and sepsis".)
Dressings are also used after surgery to cover and protect skin grafts and skin graft donor sites. (See "Skin autografting", section on 'Recipient site dressings and care' and "Skin autografting", section on 'Donor site dressings and care'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)
SUMMARY AND RECOMMENDATIONS
●Goals – Local burn wound care (table 1 and table 2) aims to protect the wound surface, maintain a moist environment, promote burn wound healing, and limit burn wound progression while minimizing discomfort for the patient. (See 'Goals' above.)
●Topical antimicrobial agents – A variety of antimicrobial agents (table 1) can be applied to the burn wound surface, which is then covered using one of several dressing materials. Commonly used topical antimicrobial agents include antimicrobial ointments (alone or in combination), silver sulfadiazine, bismuth-impregnated petroleum gauze, mafenide, and chlorhexidine. When contamination with methicillin-resistant Staphylococcus aureus (MRSA) is suspected/confirmed, directed topical antimicrobial treatment (eg, mupirocin ointment/cream) should be added. Other treatments (eg, mafenide) may be more appropriate for heavily colonized or infected burn wounds (in addition to systemic antimicrobial therapy, as indicated). Silver sulfadiazine, alone or with cerium, and povidone-iodine are contraindicated in burn patients who are pregnant or lactating, and in newborns. (See 'Antimicrobial agents' above.)
●Dressings – Nonadherent films or fine mesh gauze (in combination with topical antimicrobials) are common dressings used to cover the burn wound, but other materials (eg, films, foams, alginates, hydrocolloids, and hydrogels (table 2) can also be used depending on the qualities of the dressing and the specific needs of the burn wound. The frequency of dressing changes ranges from twice daily to weekly depending upon the choice of dressing. Dressing changes should be frequent enough to control exudate but not so frequent that they interfere with wound reepithelialization. (See 'Dressings' above.)
●Temporary burn wound coverage – Biologic graft materials and semibiologic skin substitutes can be used for temporary coverage of burn wounds to help promote healing or serve as a bridge to definitive burn wound coverage. Biologic grafts are applied only once; after the wound has reepithelialized, the graft separates from the wound. Biologic grafts are especially useful in children. (See 'Temporary burn wound coverage' above.)
●Efficacy and use of topical therapy – Aggressive wound care that includes topical agents with antimicrobial activity has been associated with a reduced incidence of invasive wound infections, but the efficacy of topical therapy has not been definitively proven. In the absence of high-quality data and no consensus, the choice can be made based on cost, availability, frequency of dressing changes, and provider familiarity. We use the following approaches to manage superficial and deep burn wounds. (See 'Efficacy and use of topical therapy' above.)
•Superficial burn wounds – Superficial burn wounds (superficial [epidermal], superficial partial thickness) are covered with dressing materials that aid with skin healing and reepithelialization. In general, superficial burns do not require antimicrobial therapy, but for extensive superficial burns, topical antimicrobials may be used to prevent colonization while maintaining a moist wound healing environment. Furthermore, because superficial partial-thickness burns may not always be easily distinguished from deeper injuries, topical antimicrobial agents are often used. We generally start with a combination antibiotic ointment or creme (eg, Polysporin) covered with a nonadherent dressing (eg, Xeroform, Adaptic, Mepitel). When in close proximity to the eyes, we use an ophthalmic ointment without steroids. (See "Treatment of superficial burns requiring hospital admission", section on 'Our approach'.)
•Deep burn wounds – Deep burn wounds (deep partial thickness, full thickness, deeper burns) ultimately require burn wound excision and graft/flap coverage. Prior to definitive care and burn wound excision, a preliminary gauze dressing is often first applied. Following eschar debridement and/or excision, if grafting will not take place immediately, for interim wound management, fine mesh gauze in combination with topical antimicrobials, typically silver-containing agents or dressings (eg, Silvadene, Sulfamylon, Acticoat), is often used to provide a moist and minimally adherent provisional dressing. (See "Treatment of deep burn injury" and "Overview of surgical procedures used in the management of burn injuries" and "Overview of the management of the severely burned patient".)
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